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Use of Tissue Adhesive to Secure Spinal Epidural Stimulating Electrodes: Technical Note Richard K. Simpson, Jr., M.D., Ph.D., John A. Halter, Ph.D., and Dennis G. Auzenne, R.N. Department of Neurosurgery, Baylor College of Medicine, Houston, Texas

Simpson RK Jr, Halter JA, Auzenne DG. Use of tissue adhesive to secure spinal epidural stimulating electrodes: technical note. Surg Neurol 1992;38:391-3.

Securing spinal cord stimulating electrodes (SCS) within the epidural space is often a challenging task. Complications of the technique include development of cerebrospinal fluid leaks and electrode migration. We report four patients who underwent a limited laminectomy for placement of epidural spinal cord stimulating electrodes to relieve pain and/or spasticity. Suturing electrodes to the dura was not possible, and a tissue adhesive was used. Two-year follow-up shows no migration of the electrodes. Tissue adhesive of "fibrin glue" is a viable alternative for securing epidural SCS electrodes. KEY WORDS: Epidural; Stimulating electrode; Tissue adhesive

Epidural spinal cord stimulating (SCS) electrodes have been used for many years to treat a variety of pain syndromes and spasticity disorders [4]. We have found the "plate" or "disk" electrodes, which require a limited laminotomy for optimal insertion, more effective than the percutaneously placed "cylindrical" electrodes. Several serious complications arising from epidural SCS electrode placement are described, including infection, hemorrhage, cerebrospinal fluid (CSF) leakage, or functional failure caused by migration [3]. We have begun to utilize tissue adhesives such as "fibrin glue" as an alternative method for securing SCS electrodes to epidural targets in an attempt to reduce complications.

after demonstrating benefits of SCS by a percutaneously inserted trial electrode. An attempt to secure the electrode with suture to the dura was made. The dura was extremely friable, because of his previous surgical procedures, scaring, and trauma. Fibrin glue was used to secure the electrode to the epidural surface, slightly eccentric to the left side. Postoperatively he had significant relief of his spasticity, and 2 years later the electrode position remained unchanged (Fig. 1 A).

Cases 2 and 3 A 44-year-old woman and a 57-year-old man with partially treated thoracic arteriovenous malformations (AVMs) had burning dysesthesias in their legs. No temporary electrode testing was attempted because of the potential risks from percutaneously inserting a large needle near an AVM. Each patient underwent a partial laminectomy and placement of an SCS electrode at the inferior margin of the AVM under direct vision. Cylindrical electrodes (eight contact leads) were used to maximize the stimulated surface area because no trial was practical. The dura revealed multiple abnormal vessels, and suturing was not attempted. Fibrin glue was used to secure the electrodes. Postoperatively the patients had significant pain relief, and 2 years later, the electrode position was unchanged (Fig. 1 B).

Case 4 Case R e p o r t s

Case I A 25-year-old man with a severe head injury and primarily left-sided spasticity underwent a limited laminectomy Address reprint requests to: Richard K. Simpson, Jr., M.D., Ph.D., Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030. Received January 19, 1992; accepted March 26, 1992.

© 1992 by Elsevier Science Publishing Co., Inc.

An active 50-year-old woman with multiple sclerosis had burning dysesthesia and spasticity primarily in her left leg. An SCS electrode was placed overlying select nerve roots, previously tested by percutaneous temporary electrodes, via a limited sacral laminectomy. The dura was thin, and fibrin glue was used to secure the contacts. She had significant pain relief and resolution of hypertonicity in her left leg. Electrode position has not changed over 1 year follow-up period (Figure 1 C). 0090-3019/92/$5.00

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Figure 1. Plain anteroposterior films of case 1 (A), case 2 (B), and case 4 (C) reveal the position of the electrodes after being secured to the dura by fibrin glue. These follow-up films, up to 2 years postoperatively, reveal that no migration of the electrode has occurred.

Fibrin Glue and Spinal Electrodes

Table 1. Summary of the Components of Fibrin Glue 1. 2. 3, 4. 5.

Thrombin 20,000 units Calcium chloride 10% (2 cc) e-Aminocaproic acid 25% (5 cc) 0.9% Sodium chloride (50 cc) Pure fibrin product (desired volume and source)

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bottle with an atomizer. T h e electrode is b a t h e d with fibrin p r o d u c t by a syringe a n d fine flexible tubing, and spray is added to set the fibrin. A u t o l o g o u s d o n o r rather than p o o l e d plasma can be used to create fibrin and r e d u c e the small possibility o f viral transmission.

Discussion

References

Sutures are generally used to secure electrodes to the dura to p r e v e n t migration; h o w e v e r , dural rents can occur and create CSF leakage [3]. Tissue adhesives are currently widely used to repair CSF leaks and for hemostasis [1,5]. R e c e n t l y their use includes c e m e n t i n g peripheral nerve repairs [2]. W e f o u n d fibrin glue an excellent alternative to suture for securing SCS electrodes to the dura and to p r e v e n t CSF leakage and migration. Saline, 50 cc, is mixed with 2 cc o f calcium chloride, 5 cc o f ~-aminocaproic acid, and 2 0 , 0 0 0 units o f t h r o m b i n (Table 1). This mixture is placed into a spray

1. Kram HB, Shoemaker WC, Clark SR, Macabee JR, Yamaguchi MA. Spraying of aerosolized fibrin glue in the treatment of nonsuturable hemorrhage. Am Surg 1991;57:381-4. 2. Maragh H, Meyer BS, Davenport D, GouldJD, TerzisJK. Morphofunctional evaluation of fibrin glue versus microsuture nerve repairs. J Reconstr Microsurg 1990;6:331-7. 3. Pineda A. Complications of dorsal column stimulation. J Neurosurg 1978;48:64-8. 4. Simpson RKJr, Robertson CS, Goodman JC, Halter JA. Recovery of amino acid neurotransmitters from the spinal cord during posterior epidural stimulation: a preliminary report. J Am Paraplegia Soc 1991;14:4-9. 5. Van-Velthoven V, Clarici G, Auer LM. Fibrin tissue adhesive sealant for the prevention of CSF leakage following transphenoidal microsurgery. Acta Neurochir 1991;109:26-9.

Use of tissue adhesive to secure spinal epidural stimulating electrodes: technical note.

Securing spinal cord stimulating electrodes (SCS) within the epidural space is often a challenging task. Complications of the technique include develo...
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